20641 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bailifing Project Identification - PERMITNO.
Iu11�gAddmsa: 4:;,;'l �► C- C J��T�� � 20641
acus: one. A p
Ti�.tl ❑rye( S CITY OF CUPERTINO-BUILDING DIVISION �r�
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Contractor's Name: LIc.No: APPLICATION / PERMITfr— v
S BNLDINGELECTWCALPLUMBINC-MECHAMCAL CATEGORY CONTROL a6
Architect/Engineer: Lk.No:
CTA' 1 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
rcSCOC> MISSTo GoLVECr
A PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION _'/-"
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCES.RESIDEMHAL JOBDESCRIPI'ION
ing with Section 7000)of Division 3 oflhe goal nessand ProfewlonsCode,and my
license Is In fullfora and effect. PANELS
License Class Conti ` ` V n
Date Contractor 701-1000 ANIS 'R(/ `
AACHITECI'S DECLARATION
p2 I understand my plansshall W used as public reauds. OVER IOW AMPS SQ.FT.FLOOR AREA 5/SQ.F[.
cO
Fj Licensed Professional SIGNS EIECTWCAL
6 w OWNER-BUILDER DECLARATION
�n a Fig SPECLILCIXCNT/M15C
y mving a .. Qutlamexemptfromthe Contractor's License Law for Anydtyhe
Fg~q county gichreci(msaper ittocoslnessandProfeabnsCode:Anydryor TEMP.
54 county which rcqulrcsa perMtloconsbuct,alter,Improve,dennlbh,or repair
q 6 any structure prior to its bauance,also mclulmsthe appliantfor such permit to POWER DEVICES
E�a�U file a signed statement that he is licensed pursuant to the provisions of the
Contractors License law(Chapter commenein Ith Samm7000 of Divi- VALUATION
O?I* ( ss ( B e ) SN,TMhtINC BOOL ELECTRIC
O slon3of the Buslnessand ProfessionsCode)orthat hebexemptthcre(romand
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES
e: appllantfora permit subjects the applicant to a civil penalty of not more than O (/
C, five hundred dollars($SM. NEW RESIDENTIAL ELECTR
F1 1,as owner of the property,or my employees with wages as their sale SQ.FL STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is Am Intended or offend for
Osa In(Sec.7064,Business and Pmfemlom Code:The Contraciot's License Law
Qj$$ does not apply to an owner of property who Wilds or lmpaves thereon,and OCGGROUP RES,UNITS
E whodoessuchwork hlmxlforthaugh hisownemploym,providel that such
improvemens are not Intended oroBered for sale.IL however the W Ilding or TOTAL:
improvement issold within oneyearofmmplMlon,the owner-bullderwlll have
thq�mnicn of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
I_I 1,as owner of the property,am exclusively contracting with licensed
PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Lw,does cot apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p," with a ALTER-DRAIN&VENT-WATFR(EN
<gN(acior0)licensed pursuant to the Contractor's License Law. BACKFLOWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sce B &P C for this mason
.1�TSI DE FeES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECFRrT'X
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a
e a rtlD ....Iate of nxnt to sell-Insure,ora RECEIPT N
anlflate of Workers'Compensation Insurance ora artifiod copythemof(Sec. GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
3800,Lab C.)
RECUPT a
Policy R GAS EA.SYSTGI-OVER 4(EA) BUILDING DI VISION FEE
S
Co������mppppppany r
�Ccnitied copy Is hereby fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID�2-L
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA200FT Dale Remi IN
(Thlssatlon need not be completed lithe permit b for oris hundred dollars
($100)A,less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ VIA
I ar ifythat in the performance of thework forwhich this permit Is Issued, J'�
1 shall oat employ any person in any manner so as to become subject to theWATER SYSTEM/.TREATING PAID;L- 4e Sbrf-'.)
Workers Compensation Laws of Callfomla. Date
Applicant
TO APPLICANT.If,after making this Certfteg,of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Reml Icy
Z Z N
should be<ume subjm to the Woriam'Compensation provisiom of the Labor TOTAL'
CC res Code,you most forthwith comply with such provisions or this permit shall be BUILDING OD
CC j deemed revokM.
III
� CONSTtkag RUCTION Is a ON LENDING AGENCY SEISMIC FEE
Thereby aorkfowhicht lsammwdssuion lending 097,C firths perform- TOT ELECTRIC FEE
0 Z once o(the workfor which this permit is sawed(Sec.3097,Civ.C.)
02 Lndcrs Name PLUMBING FEE
LL F Lnders Addmsa QTY. MECHANICAL R T FEE MECHANICAL FEE
Ian ify O C amen.Iageaocmad thin mplywthaliatynand dconinte that the yordinances radform lora FEES,A
lacormct.building complain,andtyand amhori,m pa ntnd gate laws PERMIT ISSUANCE i- �Z
} chyting to oenterulldingc°nswnlon,andhemby dpropauthorizepectionpurpos ofthio
f.. W cityWenteree to the,indemifyan d properlyfor
esste Cit purposes. ALTER ORADDR7 MECH.
? (We)agate to save,indemnify an d keep harmiev the Cly of Cupertino Date Receipt#
V
Ig Inglis ales, dgmens,coat jndexpens,swMch maymat yway ewe AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
agumsl Id a elt me of cola perm¢I /�J CONSTRUCTION TAX
y IJ{ c. °J MR HANDLING UNIT(OVER 10,000 CFM)
�lg of Applicant/Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardous HEATING UMT(TO 100,000 OTU) Date Recet tic
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code SSecilon 255374)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No '
Willtheappliantor( wt bulldingoccupantuaecquipment°rdevias DA VENTILATION rAN(SINGLE RFSID) 1 E4J ,�
which -emit —TF
mit hazardous air contaminants as defined by the Bay Area Air (-1
Quality Management District? BOILER-COMP QHP OR 100,0(10 BTU) -
r 4haveradthehvar`1i smateriala requirements under Chapter 6.95 of BORHR-COMP(OVIR 100,000 OIL) J{/
the Califodih.tifthh ildiyCode,St.io 5505,2S533and,t534.tit Oat u
� understand that if the Wilding does not cvmently have cotenant,that lt6my NEW RESIDFN7IAL MECH. SQFT
responsibility to notify the occupant of the mqulrcments which must be met aysf{{ Bes'{yllB'
prior to Issuance of a Certificate of Occupancy. fir, GBe1Is{LBO
Owner or authorisd agent Date ISSUIiDtlY: �� k'`V �
TOTAL: VVV
OFFICE COPY